DISCLAIMER: The cases / examples on this blog have been anonymised to maintain confidentiality of patients. Cases have been acquired from various international hospitals and through other medical colleagues with the intention to teach through case examples.

Wednesday, 13 May 2009

The above photo was provided as an anonymous example of an all too common arthritic disease -- rheumatoid arthritis.

As can be seen the patient has boutoniere change in the left hand, ulnar deviation of the fingers from subluxation at the MCP joints.

There is also some telescopic changes of the fingers usually a feature of psoriatic arthritis. There were no psoriatic nail changes or skin abnormalities seen.

Elbows revealed RA nodules and dislocations. The shoulders were affected as were the knees, ankles and toes.

Despite these being 'classical signs' of RA, we should not be seeing this in this day and age. We should not be seeing this because there are very effective DMARDs available to suppress RA.

This patient, if newly diagnosed today would be started on methotrexate and the dose would very rapidly be titrated to the recommended dose of 15-25mg per week or maximum tolerated dose, with a starting dose of 7.5mg per week. Sometimes if oral MTX is not effective, subcutaneous administration is tried.

DMARD treatment should not be delayed. If the inflammatory changes can be suppressed within the first 6 months of symptoms onset (early RA) then the chronic debilitating features can potentially be avoided.

This patient was on combination treatment of methotrexate, bucillamine and prednisolone. However, the dose of MTX used in Japan is usually lower than that recommended in trials e.g. 4mg. Older 'add on' DMARD therapy such as bucillamine, the cousin of penicillamine, is also still used commonly.

With the advent of MTX, leflunamide and anti-TNF antibodies, the likes of penicillamine are now rarely used in the UK. However, occasionally, patients still use drugs such as anti-malarials (hydroxychloroquine) or sulfasalazine in the UK.

Patients should no longer get to a state of being disabled by an ultimately treatable condition.

There is a real need for more expertise in treating connective tissue diseases so that patients can be managed with the most effective drugs in line with current medical evidence.

The term 'burned out' RA which this patient might appear to have is a misnomer. RA is now considered to be a continuous disorder which does not burn out. Also, such patients have an increased risk of death compared to the rest of the healthy population. Hence, it is not merely an inconvenience, it increases morbidity and mortality.

The term of 'hit it hard and hit it fast' applieds to RA. If the therapy is delayed or insufficient to suppress the arthritis, patients can end up the very same as in the photo above.

Please read UpToDate 17.1 for the latest evidence on RA. Note that penicillamine is not recommended by UpToDate for modern treatment of RA.